00020032 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,Z -0--0006"0030-1—
CITY OF CUPERTINO BUILDING. ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
V ' BUILDING PROJECTIDENTIFICATION�
-PERMIT NO
`�-
9UILDINGADDRESS:
4 113"M cg"yo-N V4lww
SANITABY NO,
APPLICATION SUBMITTAL DATE
OWNER'S AME:/L,� ONE:'
PHA6 496
CONTRACTOR'S NAME: LIC NO,
DulNOV\
NIC
❑
CONTROLly
CHITECT/ENGINEER: LIC NO:
ADDRESS:
N6t�
'CON'TACT: PHONE
- BUILDINGPERMITdNFO
❑ Consultant Fees Paid by Applicant(Initial)
BLDG EI ECT PLUMB MPGR
LICENSED CONTRACTOR'S DECLARATION
1 hereby affton than I am licensed node, pprvi,ina of chance 9 mommenam,
QTY - ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Section 7000) of Division 3 nfthe Business. and Profcsions Code, and my license's
in full farce and affect
PERMIT ISSUANCE
/
IA
RESIDENTI:
❑SFUWI. Fl KITCHEN REMODEL
APPLIANCES - RESIDENTIAI.
License Class Lie#
Date ' Compactor -
❑ADDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
ARCM rwr'S DECLARATION
I understand my plans shall be used as public records
PANELS
UP TO 200 AMPS
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENTSWIMMING POOLS
El BATH REMODEL/REPAIR ❑DEMOLITION
❑ ETHER
Arlo
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby aBirn that I oro exempt from the Contract's License Law for the
following rearm. (Section 70315. Business end Profeaons Crdc Any at,, or tunny
201-1"AMPS
OVER IIIIro AMPS
SIGNS ELECTRICAL.
which uc aims n permit to to,lmd, alter, imp mvq demolish, or repair any smmnhe
SPECIAL CIRCUIT/MISC.
-
prloetolts lesant,al�o requires nheapplleant 6rsnah permirtotilea signed statement
than he is licensed pursuant to theprovisions of the Contractor's License Law (Chapter9-
-
(ammacing with Section TOM) of Division 3ofthe Business and Profession, Code)n,
TEMP. METER OR POLE INS' P.
COMMERCIAL, _
that he is exempt therefrom and the basis for the alleged exomptim, Any vmimem of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 9031.5 by pay upplicam I.,.permit,abja,rhe applicaat to a civil penalty of
not more than R ft hundred dollars y employees
E] 1, as owner of the property, or my employees with wages as their sole compensation;
will do the work, and the stmcmm is nen intended or uttered farsaI (Sec. 9094, Bnsina,sTI-KAB
POWER DEVICES
TENANT -IMPROVEMENT FOOD SERVICE,
00
IMP VEMENT
SWIMMING POOL ELECTRIC .
end Professions Code The Contractors Llaan Low does not apply 10 an owner of
OI1ThP,TS-SWI'rCH05- NI%'I'UBNS
property who builds or improves them, and who does such work himself or through
his own employees, provided that wall improvement, ere not intended or offered for
sale, If. however, the building or improvement is sold within one year of completion the
tor -builder will have the burden of proving that he did not build or improve for par-
NEW RESIDENTIAL ELEC9'R SQ FI'.
n11
DI Sq FI',` ORAR�A $/SQ. FT,
1-I
speso f cele.).
ae owner of the property, am exclusively contracting with licensed contractors to
onstmat the project (Seo. 9044, Business and Pefessions Gude: The Contractor's Li-
FEB 8 2000
- T09'AL.
- ..
cause law dos not apply ..a owner of proper who builds of improves lin.a. and
QTY. PI:UMBINO PERMIT Y FEE
who contracts for such pmiecB with a aommemf(s) licensed pursttam to the Contractor',
PERMIT ISSUANCE
License law.-
I am exempt a der. ce. B & P C for This reason
n
C1'/
ALTER - DRAIN as VENT - WATER (EA)
2JIATON
06
n,.,.. 1/ D
WGRACE OMPENSATION DECLARATION
s .Ih. shy affirm under penalty of pujury ane of the followinK deductions:
BACK FLOW PROTECT. DEVICE
OT
-
DRAINS- FLOOR, ROOF, AREA, COND.
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compton-
,,tion, as provided for by Senior 3'100 of the Labor Aide, r dric pmomancarsf the
STORIES 'TYPE CONS] 'RUC'I'ION
^
a FIXTURES - PERTRAP _
wnrkmrwblch Nlspermitisls,uul.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
37M of the LaborCode, for the perbovertof the work fm,cluebmi, permit o; lssucd.
My Worker'aCompenammnani
Compensation lnsuaaerand oy number are:
GAS - EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP 5— APN27
akP
-
Carrier:Carrier: Polleyy NNn.:
OAS- EA. SYS '1'EM-OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS't02
COMPENSATION INSURANCE.
(Thissection needatbeoomylnedif the panni, is Area hundred doll am ($100)
m le".)
GREASEIINUUSTRL WASTP. INTF.RCF.PTOR
2
uH `p BUILDING DNIS[(SN IjBL'S- .
- -
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 FT.
I aenify that it, be penflument0flhe work derwbldt Nis pannd is issued, Limit
nen employ any parson In any tanner so as to become sobject a, the Workers' Comped-
ENERGY PEE
WATER I IEATER WNBNDELECTR
-
strom Laws of California. Dote
Applicant )
GRADING FEE
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
becommi
e milL, to the Worker's Cod,ematinn pmviv as of the Labor Code you most
WATER SYS, EMn REATING -
SOILS FEE
WATER SERVICE
1'onM1with comply with such provisions or this permit shall be deemed revoked'
NEW RESIDENTIAL PI.MB. SQ. PT.
CONSTRUCTION LENDING AGENCY
I hereby Oman that thele is a construction lending agency for the performance of
PAID
Data Receipt#
the work for which this permit is issued (Sec. 3097, Ci¢ C.)
Landw's Name
-
TOTAL:
Lender's Addles,
'TOTAL: .
1 verify that 1 have read this application and state that the above information is
BUILDING FEE
erect. l agree to comply with all city and county ordinances and state low, totaling it)
buildingconslnmd0n,,nd hereby authorize repreeatgtives of this my tobnnrulxm the
QTY, MECHANICAL PERMIT j ,FEE
's I t
-
SEISMIC FEE
above-mentioned propery for inspection purposes.
1v PERMI'1'ISSUANCE
(WO atgfm,ave, indemnify and keep hmmles, the City of Cuperido tourist
ELECTRIC FEE
liabilities, Judgments, tiers and expenses which may in any way name against said CityALTP.R
.w
in eanquence of the Granting of this Fermin.
OR ADD TO MPRH
s '.
-
PLUMBING FEE
AIR HANDLING UNIT (TO 111,BOBCFM)
MECHANICAL FEE '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOUR CP REC CATION.
AIR HANDLING ON['] (OVER 10,000 CPM)
QC)
CONSTRUCTION TAX
Inreaf Applief none me
U,?EDWSMATERIALSDISCLOSURE
EXHAUST HOOD (W/DUCD -
HOUSING MITIGATION THE
HEATING UNIT LTO 10".0a I BTU)
Will the appeal or future building occupant store or handle hazardous national
as delved by the Cupertino Muninpal Cade, Chapter 9.12, ad rho Health and Safely
Code, Secure 25532(a)?
HEATING UNIT (OVER 100,000 BTU)
-
❑Yes C] No .'
Will the applicant orfuture building moreequipment ofdevices which
us air c0maminants as define) by by thethe Bay Area Air Quality Management
emit District)
❑Yc ❑No -
PAID —'
Data Receipt it
1 VENTILATION FAN (SINGLE RE,SID)
BOILER - COMP (3HP OR IIID,(IW BTU)
TOTAL:
BOILER -COMP (OVER IW,OW BTU)
.
AIRCONDI'TIONER
I have read the hazardous materials requirements under Chaser 695 of the Cali-
9 p
- ISSUANCE DATE
NEW RESIDENTIAI. METH. SQ. CO.bOBdlnKd
tad titer If the
foobull i Health n Safety Code, Sections 25585, 25533 and 25534.1 to unity
up not,whitly hnvc. nma.IM1ul iii, my reaponsihilirymnodfy the taupem
Rhe cots whieht em' ono issuance ora Certifache Fancy.
OD
�^ '3 /� •1 Q D /o
L
ISSUED BY:
a, mtodzed t Date
TOTAL:
OFFICE
� m T T
FEB - 8 2000
i
D �
p,PpRDV� CITY UE -
�N ACCORDANCE WITH THE
COCES AND ORDINANCES
CUPERTIN�' ' 00---
)ATE �i
SIGN v,:crflratioositis
ThisEs �D omes analterations
be kept onta\oec or ifom
tpermission
on Sam
m.�Y,', , r Gupe�tino.
the bm du r;3.0na sPbG
eciticatioam
P
SHAt of t'ne v,ei�c�n �„
SPP aCnv O d,0 nce or $tate
i.
1�t l s e
h
W � '
0
"j 6=1TG�EtJ
0:..
OLD PLA"S-
i2i.1- Z"
/4
LL= 4 -
AN,
Iii �3 I- 9L
0
wue
114
APPROVED
- --------
ACCORDANCE WITH THE CITY or
IV -O`' CUPERTINO CODES, AND ORDINANM
SIGNED
This set of P .1 J�C,Nnations MUST
be kept on the I tli-itts it is
and un
lawful to ma'., a, ',i - or alterations
on same vimnfj�, ;.armission
"I from
_i Lb�
the building Cupertino.
T�l
The stamping c.; A. p;p,i avid specifications
SHALL NOT be ;;eta to permit or to be an
!By
I if of the violatioll of any 0z.-)rcz6n60
wi�l E5TM .4 i li
ity Ordinance tr State
Iii �3 I- 9L
0
wue
114